Authors:
H. Fraig, D. M. R. Gibbs, G. Lloyd-Jones, N. R. Evans, G. S. Barham & H. V. Dabke

Hospital:
Salisbury District Hospital NHS Foundation Trust

Aims:
This study evaluated the impact of the Salisbury Protocol for Assessment of Cauda Equina Syndrome (SPACES) on the waiting time for MRI in patients presenting with suspected Cauda Equina Syndrome (sCES) within a UK district general hospital.

Patients and methods:
All consecutive patients undergoing an MRI scan in our hospital, for sCES, over a 12-month period, prior to and following the
Introduction of SPACES, were identified. Patient’s gender, age, MRI diagnosis, time from MRI request to imaging and outcome were recorded.

Results:
In the year prior to the introduction of SPACES, 66 patients underwent MRI for sCES, out of which 10.6% had cauda equina compression (CEC), 63.5% had other spinal pathology and 25% had a normal scan. In the year after introduction of SPACES, 160 patients underwent MRI for sCES out of which 6.2% had CEC, 70.7% had other spinal pathology and 23% had a normal scan. Despite the referrals for sCES increasing by more than 2-fold following the introduction of SPACES, the median time from MRI request to scan decreased from 9.1 to 4.2hours (p1⁄40.106, Mann-Whitney-U) and the number of patients transferred to the regional hub hospital decreased from 7 to 3.

Conclusions:
Implementation of SPACES for patients with sCES resulted in a substantial reduction in waiting time for MRI and decreased the number of transfers to the regional hub hospital. Based on our early experience, we encourage other centres within the UK to introduce such a pathway locally, to improve the management of patients with sCES.

Authors:
Philippa Bennett, Antonella Ardolino, Robin Elliot

Hospital:
Basingstoke North Hampshire Hospital

Introduction:
For over 20 years NHS Trusts in England have had the percentage utilisation of their elective lists monitored as a key performance indicator. There has been renewed focus on this in the wake of the Covid pandemic, and the subsequent effect on waiting lists. Currently, a target of 85% utilisation is strived for across all elective lists. No similar target exists for trauma, despite this accounting for 30% of cases within the orthopaedic department. Our department aimed to establish a system to monitor trauma theatre utilisation and identify areas for improvement.

Methods:
Within HHFT a weekly ‘Trauma Communications Cell’ (TCC) was established to allow collaboration between wards, theatres, anaesthetists and surgeons. Along with overall utilisation, specific indicators were monitored including delays to start times and reasons for delays. Theatre managers across the region were contacted for their average trauma theatre utilisation over the preceding six months.

Results:
Over the first six month period of the TCC, trauma theatre utilisation was 79% (62-85% range). Theatre start times improved by an average of 11 minutes. Of the six Trusts contacted for their trauma theatre utilisation statistics in Wessex, three replied. Of these one did not know their trauma theatre utilisation. Of the other two, one had utilisation of 70%, and the other 66%.

Conclusions:
Monitoring trauma theatre utilisation is an effective way to improve workload. Establishing a weekly forum for problems to be identified improves team cohesion and helps to improve efficiency.

Authors:
Barry Mullins, Alisdair Felstead, John McFall, Harry Akehurst, Andrew Jowett, Togay Koc

Hospital:
Queen Alexandra Hospital

Introduction:
Posterior malleolar fracture morphology is increasingly being recognised as an important variable in the management of ankle fractures. In this study we compare the interobserver and intraobserver reliability of three different posterior malleolar classification systems.

Methods:
Forty computed tomography scans demonstrating ankle fractures with posterior malleolar components were reviewed by four reviewers on two separate occasions. The Mason & Molloy, Haraguchi and Bartonicek classification systems were used by the reviewers. The reviewer group included two consultant foot & ankle surgeons, one foot & ankle fellow and one specialist registrar, all familiar with the three classification systems. An interobserver and intraobserver reliability study were completed using Fleiss kappa (k) and Mean Cohen’s kappa (k) coefficient respectively. This was completed using R software.

Results:
The Fleiss kappa statistic for interobserver reliability was 0.43 (95% CI 0.35 – 0.50) for Bartoníček, 0.65 (0.56 – 0.75) for Haraguchi and 0.63 (0.55 – 0.72) for Mason & Malloy classifications. Mean Cohen’s kappa for intraobserver reliability was 0.66 (range 0.58 – 0.78) for Bartoníček, 0.73 (range 0.63-0.84) for Haraguchi and 0.65 (range 0.61 – 0.70) for Mason & Malloy classifications.

Conclusions:
The Haraguchi classification had the highest interobserver and intraobserver reliability. The interobserver reliability agreement was ‘substantial’ (0.61 – 0.80) for all classifications except Bartoníček. While the Haraguchi classification is descriptive and has been utilised widely in previous research, the Mason & Malloy classification has prognostic value, which can aid in decision making whilst retaining substantial interobserver reliability. The Bartoníček classification emphasises the importance of syndesmotic incisural involvement and its role in decision making but demonstrated the lowest interobserver reliability.

Authors:
Shih-Han Chen, Lina Chevalier, David Howard, Toby Briant-Evans, Geoffrey Stranks, Jamie Griffiths

Hospital:
Hampshire Hospitals NHS Foundation Trust

Introduction:
Complex hip procedures often require specialist surgeons, pre-operative planning and work-up. There is increasing literature suggesting that MDTs improve patient care.
The GIRFT, BHS and BOA guidelines recommend that MDT outcomes should clearly document the surgical indications and decisions.
We studied the impact of implementing an e-referral system to the hip MDT at a district general hospital.

Methods:
Hip MDT outcomes on electronic patient records were audited against the joint standards.
During the first audit (March to June 2021), referrals were facilitated by a single MDT coordinator.
An e-referral system was integrated into EPR over Summer 2021.
A re-audit (November 2021 to February 2022) was performed to close the loop.

Results:
In the first audit, 45 cases (34 patients) were identified in 6 MDTs. Only 47% had documented outcomes.
After implementing e-referrals, the re-audit identified 55 cases (31 patients) in 7 MDTs. 85% had documented outcomes. 71% were auditable directly via the e-referral system.

Conclusions:
The implementation of an e-referral system significantly improved the standard of documentation of hip MDT outcomes (χ2=20.2, p<0.001).
We identified the need for an e-referral system tailored for the MDT process, as our current technical implementation (based on generic inter-departmental templates) still had room for improvement.
A working group is currently exploring options for further improvement and expansion, in preparation for the regional MDT process.

Recommendations:
– Hip MDTs should be supported by an e-referral system
– E-referral systems should be tailored for MDTs
– Appropriate support and funding for MDTs improve patient care

Authors:
Louise McMenemy, Behan FP, Kaufmann J, Cain D, Bennett AN, Boos C, Fear NT, Cullinan P, Bull AMJ, Phillips ATM, McGregor AH

Hospital:
Academic Department of Military Trauma and Surgery, Birmingham

Introduction:
A disproportionate number of young lower-limb amputees are diagnosed with osteopenia/osteoporosis, increasing lifetime risk of fragility fracture and challenging traditional osteoporosis treatment paradigms. The association between traumatic injury, amputation, and bone health is uncertain. The aim was to test the hypothesis that trauma results in a systemic reduction in Bone Mineral Density (BMD), as well as a localised BMD reduction in the amputated limb of lower limb amputees, that is progressively greater with higher level amputations.

Methods:
Cross-sectional analysis of a cohort study comprising 579 male adult UK military personnel with combat related traumatic injury (CRTI) (including 153 lower limb amputees) and 565 frequency-matched uninjured men. BMD was assessed using DEXA scanning of the hips and lumbar spine.

Results:
Femoral neck BMD was lower in the CRTI than the uninjured group (T-score -0.08 vs -0.42 p=0.000). Subgroup analysis revealed this reduction was significant only at the femoral neck of the amputated limb of amputees (p=0.000), where the reduction was greater for above knee amputees than below knee amputees (p=0.037). There were no differences in spine BMD.

Conclusions:
Changes in bone health appear to be mechanically driven rather than systemic and are only evident in those with lower limb amputation. This may arise from altered joint and muscle loading creating a reduced mechanical stimulus to the femur which we propose is an unloading osteopenia. This diagnostic distinction may prevent inappropriate use of systemic treatment and will, we hope, drive research into the ideal loading environment to potentially reverse BMD changes.

Authors:
Gregory Neal-Smith, Daniel Marsland, Robin Elliot

Hospital:
North Hampshire Hospitals

Introduction:
Diagnostic uncertainty is common when treating foot and ankle pathology, due to complex anatomy or previous surgery. Single Photon Emission Computed Tomography-CT (SPECT-CT) has emerged as a novel tool and combines gamma radiation with traditional CT to accurately identify sites of pathology and pain generation. A recent study showed that SPECT-CT led to a change of management in 48% of the patients when compared with diagnosis based on MRI. The aim of the current study was to demonstrate the diagnostic value of SPECT-CT in foot and ankle surgery.

Methods:
Data was collected on all SPECT-CT imaging ordered by a single foot and ankle consultant between September 2020 and March 2022. 47 patients were included, and patient notes were reviewed to investigate the reasons for using this imaging modality.

Results:
Three broad categories were identified where SPECT-CT can be particularly useful: pre-operative surgical decision making in the complex degenerate foot; pain after total ankle replacement; and pain after fusion surgery. We present cases to highlight how SPECT-CT scans influence decision making in managing complex foot and ankle pathology.

Conclusions:
We have found SPECT-CT to be a valuable tool when there is diagnostic uncertainty despite traditional imaging modalities. It can help guide further treatment and reduce the need for unnecessary or incorrect surgery. Large, prospective studies on the use of SPECT-CT are required to further define the role of SPECT-CT and its impact upon success rates of surgery.

Authors:
Aliabbas Moosa, Kirsty Cole, Mahmoud Elmesalmi, Rawad Azaz, Henry Rowe, Amanda Rhodes, Toguy Koç

Hospital:
Queen Alexandra Hospital

Introduction:
The Achilles tendon is the most frequently ruptured tendon. Treatment outcomes depend upon prompt diagnosis and management. A local study in 2018 highlighted inefficiencies in the patient pathway. Key areas were identified for service redesign and improvement. This study aimed to evaluate the impact of a revised, novel pathway on the timescales from presentation to ultrasound diagnosis and definitive treatment decision.

Methods:
All suspected Achilles tendon ruptures from April 2021 to March 2022 were retrospectively reviewed through electronic records. Information regarding the period from presentation to diagnosis and subsequent treatment decision was collected. Timescales were compared to those in the 2018 study. Performance was also assessed against local departmental standards and the Swansea Morriston Achilles Rupture Treatment (SMART) protocol.

Results:
In total 87 patients were identified, of whom all received an ultrasound examination. Departmental standards were met in most cases; 93% (n=81) diagnosed within one week of presentation and 96.5% (n=84) given a treatment decision within two weeks. In the 2018 study, these figures were 78% and 83% respectively.
When compared with timeframes developed for the SMART protocol, 34% (n=30) were scanned within 48 hours of presentation. Compared to the 2018 study, this is an improvement but remains below target.

Conclusions:
Since the Introduction of the new pathway, there has been a significant improvement in the number of patients diagnosed within one week and offered a treatment decision within two weeks (p<0.05). This completed audit cycle demonstrates an effective pathway to expedite diagnosis and treatment for Achilles tendon ruptures.